Healthcare Provider Details

I. General information

NPI: 1528945227
Provider Name (Legal Business Name): KRISTEN GOODRICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 08/31/2025
Certification Date: 08/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 SWEETWATER SPRINGS BLVD STE G
SPRING VALLEY CA
91978-1725
US

IV. Provider business mailing address

PO BOX 161328
SAN DIEGO CA
92176-1328
US

V. Phone/Fax

Practice location:
  • Phone: 619-734-7112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number17154
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: